CMS Pub. 100-02, ch. 15, § 60.4.1

Benefit

(Rev. 192, Issued: 08-01-14, Effective: 09-02-14, Implementation: 09-02-14)

This definition applies to homebound for purposes of the Medicare home health benefit.

For a patient to be eligible to receive covered home health services, the law requires that a physician certify

in all cases that the patient is confined to his/her home. For purposes of the statute, an individual shall be

considered “confined to the home” (homebound) if the following two criteria are met:

1. Criteria-One:

The patient must either:

- Because of illness or injury, need the aid of supportive devices such as crutches, canes,

wheelchairs, and walkers; the use of special transportation; or the assistance of another person in

order to leave their place of residence

OR

- Have a condition such that leaving his or her home is medically contraindicated.

If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional

requirements defined in Criteria-Two below.

2. Criteria-Two:

- There must exist a normal inability to leave home;

AND

- Leaving home must require a considerable and taxing effort.

If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the

absences from the home are infrequent or for periods of relatively short duration, or are attributable to the

need to receive health care treatment. Absences attributable to the need to receive health care treatment

include, but are not limited to:

• Attendance at adult day centers to receive medical care;

• Ongoing receipt of outpatient kidney dialysis; or

• The receipt of outpatient chemotherapy or radiation therapy.

Any absence of an individual from the home attributable to the need to receive health care treatment,

including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment

in an adult day-care program that is licensed or certified by a State, or accredited to furnish adult day-care

services in a state, shall not disqualify an individual from being considered to be confined to his home. Any

other absence of an individual from the home shall not so disqualify an individual if the absence is of an

infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the

purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. It

is expected that in most instances, absences from the home that occur will be for the purpose of receiving

health care treatment. However, occasional absences from the home for nonmedical purposes, e.g., an

occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral,

graduation, or other infrequent or unique event would not necessitate a finding that the patient is not

homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do

not indicate that the patient has the capacity to obtain the health care provided outside rather than in the

home.

Some examples of homebound patients that illustrate the factors used to determine whether a homebound

condition exists would be:

• A patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in

order to walk;

• A patient who is blind or senile and requires the assistance of another person in leaving his or her

place of residence;

• A patient who has lost the use of the upper extremities and, therefore, is unable to open doors, use

handrails on stairways, etc., requires the assistance of another individual to leave his or her place of

residence;

• A patient in the late stages of ALS or neurodegenerative disabilities. In determining whether the

patient has the general inability to leave the home and leaves the home only infrequently or for

periods of short duration, it is necessary to look at the patient’s condition over a period of time rather

than for short periods within the home health stay. For example, a patient may leave the home

(under the conditions described above, e.g., with severe and taxing effort, with the assistance of

others) more frequently during a short period when, for example, the presence of visiting relatives

provides a unique opportunity for such absences, than is normally the case. So long as the patient’s

overall condition and experience is such that he or she meets these qualifications, he or she should be

considered confined to the home.

• A patient who has just returned from a hospital stay involving surgery who may be suffering from

resultant weakness and pain and, therefore, his or her actions may be restricted by the physician to

certain specified and limited activities such as getting out of bed only for a specified period of time,

or walking stairs only once a day, etc.;

• A patient with arteriosclerotic heart disease of such severity that the beneficiary must avoid all stress

and physical activity; and

• A patient with a psychiatric illness that is manifested in part by a refusal to leave home or is of such

a nature that it would not be considered safe for the patient to leave home unattended, even if he or

she had no physical limitations.

The aged person who does not often travel from home because of feebleness and insecurity brought on by

advanced age would not be considered confined to the home for purposes of this reimbursement unless they

meet one of the above conditions above.